The breathing crisis at Excelcare at Newark began during the early morning hours of November 25, when the resident started complaining of shortness of breath around 3 a.m. Her oxygen saturation had fallen to 88 percent, well below normal levels, and nursing staff immediately placed her on oxygen at 5 liters per minute through a non-rebreather mask.
By 5:51 that morning, the situation had deteriorated enough that staff called 911 for emergency assistance.
But federal inspectors found no evidence that anyone at the facility had contacted the resident's physician about her respiratory distress, even as her condition required both oxygen therapy and eventual emergency medical intervention.
The resident, identified in inspection records as R1, had been admitted to Excelcare with a right femur fracture. Two days before the breathing emergency, she had already shown signs of respiratory problems during a therapy session.
On November 23 at 2:52 p.m., a certified occupational therapy assistant documented that the resident "presents with labored breathing, oxygen saturation of 89%." The therapy session was cut short because she was "unable to participate."
Even then, inspectors found no record that medical staff consulted with her physician about this new onset of respiratory distress.
When investigators interviewed the licensed practical nurse who responded to the November 25 emergency, she described finding the resident in obvious distress. "I answered the call bell," the nurse said. "R1's roommate said that R1 can't breathe. I saw R1 and she didn't look well. R1 said she couldn't breathe. R1 was at 88%. I put her on O2 at 2 liters."
The nurse placed the timing between 3 and 4 a.m., before her scheduled break.
The therapy assistant who had worked with the resident on November 23 told inspectors she had immediately reported the breathing problems to nursing staff. "I remember R1 did not do therapy that day," she said. "I asked why she couldn't do therapy. R1 told me she couldn't do therapy because of her breathing. I checked her vitals and put them in my note. I told the nurse whose cart was immediately outside of R1's room."
Despite this direct communication between therapy and nursing staff about the resident's breathing difficulties, facility records show no evidence that anyone contacted her physician.
Federal regulations require nursing homes to immediately notify residents' doctors about significant changes in condition. Respiratory distress severe enough to require oxygen therapy and emergency medical services clearly meets that threshold.
The inspection, conducted as a complaint investigation on December 23, found that Excelcare had failed to follow this basic communication requirement. When investigators presented their findings to facility administrators during interviews and an exit conference, management confirmed the violations.
The resident's breathing problems had been evident for days before the emergency. Her oxygen levels were consistently below normal during both the therapy session on November 23 and the early morning crisis on November 25. Staff recognized the severity - they shortened therapy sessions, started oxygen treatment, and ultimately called paramedics.
What they didn't do was pick up the phone to call her doctor.
The facility's failure to consult with the resident's physician meant her medical provider remained unaware of a significant change in her respiratory status. This left the doctor without crucial information needed to adjust her treatment plan, order additional tests, or modify her medications.
EMS documentation from the November 25 emergency call confirmed that nursing staff had placed the resident on oxygen therapy after she began complaining of shortness of breath around 3 a.m. But by the time paramedics arrived at 7:04 a.m., the situation required emergency transport.
The inspection classified this as a violation affecting few residents with minimal harm or potential for actual harm. But for the resident who couldn't breathe in the early morning hours, the failure to involve her physician represented a fundamental breakdown in basic medical communication.
Her roommate had to sound the alarm that she couldn't breathe. Staff responded with oxygen and eventually emergency services. But her doctor never got the call.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Excelcare At Newark LLC from 2025-12-23 including all violations, facility responses, and corrective action plans.